Provider Demographics
NPI:1538637152
Name:KRUTULIS, MICHELLE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:KRUTULIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 COMMERCE BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:DICKSON CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18519-1762
Mailing Address - Country:US
Mailing Address - Phone:570-489-5561
Mailing Address - Fax:570-489-5563
Practice Address - Street 1:851 COMMERCE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1762
Practice Address - Country:US
Practice Address - Phone:570-489-5561
Practice Address - Fax:570-489-5563
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN240445L163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent